TECM Clínica Médica Practice Questions - TECM - Título de Especialista em Clínica Médica (SBCM, Brazil) Exam - TECM Clínica Médica Practice Questions - TECM - Título de Especialista em Clínica Médica (SBCM, Brazil) Exam

Question 1

A 62-year-old male with ischemic cardiomyopathy and NYHA Class III heart failure has a left ventricular ejection fraction (LVEF) of 28% despite optimized treatment with enalapril 20 mg BID, carvedilol 25 mg BID, and spironolactone 25 mg daily. His blood pressure is 118/74 mmHg, heart rate is 68 bpm (sinus rhythm), serum potassium is 4.4 mEq/L, and eGFR is 58 mL/min/1.73 m². According to the Diretriz Brasileira de Insuficiência Cardíaca (SBC), what is the most appropriate next step in disease-modifying therapy?

Switch enalapril to sacubitril/valsartan (with a 36-hour washout period) and add an SGLT2 inhibitor (dapagliflozin or empagliflozin). Discontinue carvedilol and initiate ivabradine, while maintaining enalapril and spironolactone. Add digoxin 0.25 mg daily and increase spironolactone to 50 mg daily without changing enalapril. Add amlodipine 10 mg daily to achieve afterload reduction and lower neurohormonal activation.

Correct Answer:

Switch enalapril to sacubitril/valsartan (with a 36-hour washout period) and add an SGLT2 inhibitor (dapagliflozin or empagliflozin).

Question 2

A 58-year-old male presents to the emergency department (Unidade de Pronto Atendimento - UPA) with crushing substernal chest pain of 90 minutes' duration radiating to the left arm. Electrocardiogram reveals 3 mm ST-segment elevation in leads V1–V4 with reciprocal ST depression in II, III, and aVF. The nearest PCI-capable hospital is 3 hours away by ground ambulance. According to Brazilian acute coronary syndrome guidelines, what is the best immediate reperfusion strategy?

Administer intravenous fibrinolytic therapy (e.g., tenecteplase or alteplase) immediately within 10 minutes (door-to-needle), followed by transfer for pharmaco-invasive coronary angiography within 2 to 24 hours. Transfer the patient immediately for primary percutaneous coronary intervention (PCI) without administering fibrinolytics, regardless of transport delay. Administer unfractionated heparin and double-dose statin, observe clinical response for 6 hours, and perform elective angiography if pain persists. Perform emergency bedside pericardiocentesis and start therapeutic anticoagulation with enoxaparin.

Correct Answer:

Question 3

A 71-year-old female with a history of hypertension, type 2 diabetes, and permanent non-valvular atrial fibrillation has normal renal function. She has no history of stroke, TIA, or vascular disease. According to the CHA2DS2-VASc score and Brazilian cardiology consensus, what is her score and recommended stroke prevention strategy?

Score = 4; oral anticoagulation with a Direct Oral Anticoagulant (DOAC, e.g., apixaban, rivaroxaban, dabigatran, or edoxaban) is strongly recommended. Score = 2; antiplatelet monotherapy with acetylsalicylic acid (aspirin) 100 mg daily is the preferred first-line therapy. Score = 1; no antithrombotic or anticoagulant therapy is indicated given preserved left ventricular function. Score = 5; combination therapy of warfarin plus clopidogrel and aspirin (triple therapy) is mandatory indefinitely.

Correct Answer:

Score = 4; oral anticoagulation with a Direct Oral Anticoagulant (DOAC, e.g., apixaban, rivaroxaban, dabigatran, or edoxaban) is strongly recommended.

Question 4

A 48-year-old male with untreated hypertension presents to the emergency department with severe throbbing headache, blurred vision, and dyspnea. Vital signs show BP 224/132 mmHg, HR 96 bpm, RR 26 bpm, and SpO2 90% on room air. Fundoscopy reveals bilateral flame-shaped hemorrhages, cotton-wool spots, and bilateral optic disc swelling (papilledema). Chest radiograph demonstrates diffuse pulmonary edema. What is the diagnosis and the most appropriate immediate pharmacological management?

Hypertensive emergency with acute pulmonary edema and malignant nephrosclerosis/retinopathy; initiate continuous intravenous sodium nitroprusside or nitroglycerin with intravenous furosemide, targeting a 20% to 25% reduction in mean arterial pressure within the first hour. Hypertensive urgency; administer oral clonidine 0.2 mg or sublingual captopril 25 mg and discharge with outpatient follow-up in 48 hours. Pseudohypertension; administer oral lorazepam and repeat blood pressure measurement in 3 hours. Hypertensive emergency; rapidly decrease systolic blood pressure to below 100 mmHg within 15 minutes using boluses of hydralazine.

Correct Answer:

Question 5

A 54-year-old male with a history of bicuspid aortic valve presents with 3 weeks of low-grade fever, malaise, night sweats, and a new holosystolic regurgitant murmur at the apex. Physical exam reveals non-tender erythematous macules on the palms (Janeway lesions) and subungual splinter hemorrhages. Blood cultures (3 sets drawn over 2 hours) grow Streptococcus gallolyticus (formerly S. bovis). In addition to targeted antibiotic therapy and echocardiography, what essential diagnostic investigation must be scheduled?

Total colonoscopy to screen for occult colorectal neoplasia or adenomatous polyps. Gastroduodenoscopy to identify occult Helicobacter pylori gastric ulceration. Bone marrow aspirate and biopsy to rule out acute myelogenous leukemia. 24-hour urine copper and ceruloplasmin testing to evaluate Wilson's disease.

Correct Answer:

Total colonoscopy to screen for occult colorectal neoplasia or adenomatous polyps.

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Prepare with the TECM Clínica Médica Practice Questions - TECM - Título de Especialista em Clínica Médica (SBCM, Brazil) Exam practice quiz. This question bank includes 100 questions covering year-old, presents, serum, male, and mmhg. Use it to review important concepts, identify knowledge gaps, and build confidence for the related exam, course, or assessment.

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TECM Clínica Médica Practice Questions - TECM - Título de Especialista em Clínica Médica (SBCM, Brazil) Exam

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TECM Clínica Médica Practice Questions - TECM - Título de Especialista em Clínica Médica (SBCM, Brazil) Exam

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